| Abstract|| |
India ratified the WHO's Framework Convention on Tobacco Control in February 2004 and enacted legislation called, "Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act 2003" which specifically called for an end to direct and indirect form of tobacco advertisements. Under its Section 7, the Act also stipulates depiction of pictorial health warnings on all tobacco products. Since the enactment of the legislation, the tobacco companies are prohibited from any kind of advertisement. However, studies show that the instances of showing smoking in movies have increased significantly to 89% after the implementation of the Act. The brand placement has been also increased nearly three folds. Association of tobacco with glamour and style has also been established. Seventy-five percent of movies have showed the lead character smoking tobacco. The instances of females consuming tobacco in movies have also increased, pointing toward a specific market expansion strategy by tobacco companies using movies as a vehicle. General public does not feel that banning tobacco scenes in the movie will affect their decision to watch movies or the quality of movies. It was found that favorable images through mass media created a considerable influence on youngsters and increased their receptivity to tobacco smoking. Pictorial warning on tobacco products is yet to start. Tobacco industry's opposition to tobacco health warnings is understandable as it will adversely affect their business. However, policymakers should not evade their responsibility to mandate strong health warnings on all tobacco product packs. Legal action against offenders, investigation of the relationship and financial irregularities between film-makers and tobacco industry, and recall of the movies showing tobacco brand are the important measures recommended.
Keywords: Cigarettes and other tobacco products act 2003, frame-work convention on tobacco control, tobacco smoking
|How to cite this article:|
Jiloha RC. Tobacco smoking: How far do the legislative control measures address the problem?. Indian J Psychiatry 2012;54:64-8
| Introduction|| |
Smoking is one of the most common forms of tobacco consumption and a leading cause of preventable deaths all over the world.  Tobacco is the second major cause of mortality leading to the death of one in ten adults worldwide, accounting for about 5 million deaths every year. If the current trend of tobacco smoking continues, it will cause some 10 million deaths each year by 2020.  Today, there are about 1.3 billion tobacco smokers worldwide, half of these (about 650 million) will eventually die prematurely due to tobacco-related diseases.  Tobacco is the fourth most common risk factor for disease worldwide.
In India, tobacco smoking is one of the major causes of deaths and disease accounting for over eight lakh deaths every year,  and prevalence of smoking is significantly higher in psychiatric patients.  The economic costs of tobacco use are equally devastating. In addition to the high public health costs of treating tobacco-caused diseases, tobacco kills people at the height of their productivity, depriving families of breadwinners and nations of a healthy workforce. ,,
Tobacco is derived from a plant grown by about 100 countries around the world. The top ten producers, most of which are developing countries, produce 80% of the world's total tobacco.  It is consumed both in smokeless and smoke form. Tobacco smoke contains around 4,000 chemicals of which nicotine is the most potent ingredient responsible for a number of pathophysiological changes in the smoker's body. Not only that, it is highly addictive and causes the smoker to repeatedly smoke tobacco in order to maintain nicotine blood levels. This is the reason that people smoke tobacco despite of its being so deadly. In addition, exposure to tobacco products helps in initiating and maintaining smoking behavior.  Over a period of time and after extensive research, it has been found that tobacco advertisements, sponsorship, pictorial promotion of smoking in movies and television programs, and easy availability are major influences for a person to initiate tobacco consumption. Images depicting smoking promote harmful and deleterious habit of smoking among youngsters. 
WHO's Framework Convention on Tobacco Control (FCTC), an international treaty of global dimension, expressed their concern about the advertising, promotion, and sponsorship in no unclear term that "Parties to this convention (are) seriously concerned about the impact of all forms of advertising, promotion and sponsorship aimed at encouraging the use of tobacco products." 
From the same concern, Indian Government banned all forms of direct and indirect forms of advertising, promotion, and sponsorship through the "Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act" (COTPA) as a multi-measure law in 2003 while the world was still negotiating the WHO's FCTC. India ratified the FCTC in 2004. 
The Act intends to protect public health, encompasses a wide array of evidence-based strategies to reduce tobacco consumption. Rules related to the implementation of the key provisions of the Act have been notified on February 25, 2004 and came into effect from May 1, 2004, nearly a year ahead of coming into force of the FCTC. The key provisions include prohibition of smoking in public places, advertisement, and sale to minors. Under its Section 7, the Act also stipulates depiction of pictorial health warnings on all tobacco products. 
Through a Public Interest Litigation, in the Himachal High Court in 2004, the process of displaying pictorial warning on tobacco products began. Government of India notified the Rules on Packaging and Labelling in July 2006. Law suits by tobacco companies brought the case to the Supreme Court. The Supreme Court ruled in this matter on May 6, 2009, ordering the implementation of pictorial health warnings from May 31, 2009. 
The above legal provisions are in place for quite some time; this write-up reviews the impact of these provisions on the display of pictorial warning on tobacco products and depiction of smoking in movies and television programs after the Act came into effect.
| Pictorial Health Warning|| |
Pictorial health warnings on tobacco products are an important source of conveying information on adverse health effects of tobacco smoking. , A smoker who smokes 20 cigarettes a day is potentially exposed 7 300 times/year to the pictorial warnings. 
Since tobacco smoking in India is inversely related to education and is the highest among the illiterate and low literate groups,  pictorial health warnings will help to reduce the disparities in health knowledge by providing the poor and rural tobacco users with regular access to health information. The tobacco industry communicates with its target audience through "on pack advertising." Packages are created to be highly appealing and divert attention from the harmful effects of tobacco products. Pictorial health warnings can effectively counter these promotional efforts by displaying highly unappealing images of the health effects of tobacco use. These will serve to inform the consumers and also clear any deceptive messaging used by the tobacco industry to market their products as "light" or "mild." ,
It is going to be two years since it was notified, pictorial health warning is yet to appear on tobacco products. Even after pictorial health warnings start appearing on tobacco products, there will be the loose sale of cigarettes and beedis. The need of the hour is a strong demand for immediate implementation of the already notified health warnings, even though they are not strong enough. This needs to be followed by advocacy, based on field research on the limited impact of the weak warnings, for replacement with stronger pictorial health warnings. The tobacco industry's opposition to tobacco health warnings is understandable as they fear that strong warning labels will adversely affect their business. However, policymakers and governmental agencies, whose primary duty is public health protection, should not evade their responsibility to mandate strong health warnings on all tobacco product packs. The government needs to simultaneously frame policies to curb the sale of singles, a common practice in India where poor consumers cannot afford to buy full packs. Otherwise, a tobacco user will miss the opportunity of receiving health information from tobacco product packages. 
| Tobacco Smoking in Movies and Television|| |
India produces more than 900 films a year in different languages watched by over 188 million viewers every year. Satellite television has increased the reach out to a much larger audience. There are more than 10 movie channels that telecast movies round the clock. Newly released films are aired on TV within six months of their debut in theatres, taking them to the remotest corners of the country. 
There is ample scientific evidence that movies influence youngsters. The impact movies create on promoting tobacco products is also now well understood. It is known that social learning through mass media is a major factor which contributes to adoption of smoking by young people.  The use of tobacco in television dramas and in movies reinforces misleading ideas that smoking is socially acceptable and desirable.  Adolescents exposed to high pervasiveness of smoking in movies associate it with a perception that smoking is a normative social and stress reaction behavior and depiction of smoking in movies and television appears to operate through promoting more favorable attitudes toward smoking even among never-smokers.  This results in making the teenagers watching these "smoking films" as the most exposed to start smoking. In popular contemporary movies, smoking is frequently associated with characteristics that many adolescents find appealing, such as toughness, sexiness, and rebelliousness,  from privileged elites, making smoking more attractive to audience members. Because 99.6% of characters suffer no life-threatening consequences from smoking on screen, smokers seem invincible, contradicting tobacco's role as a leading cause of preventable deaths. 
It is generally argued by the film makers that by showing the smoking scenes, they are depicting the real picture of the social life. But it is not true. Research has documented that smoking was three times more prevalent in movies than in the general population from 1960 to 1990. 
This has made smoking in movies as the most powerful pro-tobacco influence on kids today, accounting for 52% of adolescents who start smoking, an effect even stronger than cigarette advertising.  Feature films can be used in marketing tobacco to adolescents as they are an acceptable format of communication and young people like going to the movies.  It has been established that children who are more receptive to such exposure are also more susceptible to start smoking. 
It has been found that adolescents who choose movie stars who use smoke on screen are significantly more likely to have an advanced smoking status and more favorable attitudes toward smoking than adolescents who choose nonsmoking stars. The portrayal of tobacco use in contemporary motion pictures, particularly by the stars admired by adolescents, contributes to adolescent smoking.  Results of two cross-sectional studies indicated that adolescents were more likely to have tried smoking if their favorite movie stars smoked on screen. , The young people exposed to movies showing actors smoking often identify tobacco with the stress-relieving, despite being well aware of the harmful health effects. Its acceptability as part of a "cool" image is also well established. Positive images of smoking in the media have the potential to downplay the serious health consequences of smoking by portraying it in a way that young people interpret as a normal part of everyday life. Such movies and stars also encourage a more neutral or tolerant attitude toward smoking among young people and therefore act to counteract other health promotion efforts to reduce teenage smoking. 
Studies show that the likelihood of an adolescent trying smoking was directly linked to the number of exposures he/she had of smoking scenes in the films.  Adolescents aged 10 to 14 years had a higher risk of smoking initiation as their exposure to movie smoking increased. The increased risk of smoking initiation associated with exposure to smoking in the movies was similar to that of other well-known risk factors, such as having a parent or sibling who smokes. This increased risk was seen across youth of all racial and ethnic groups, in all geographic regions. 
Researchers have found that 38% of adolescents aged 10 to 14 years who tried cigarettes did so because they saw smoking in movies.  A relationship of increased risk of smoking initiation with the greatest exposure to movies showing smoking has been established across all racial and ethnic groups. 
Studies have suggested that tobacco companies specifically position their products to attract female smokers from all segments, strata, and age groups of society. The tobacco companies' communications targeting females are carefully designed for younger women, stressing on female camaraderie, self confidence, freedom, and independence; cigarette brands for older women are tailored to address the needs for pleasure, relaxation, social acceptability, and escape from daily stresses.  Prevalence of smoking in films featuring popular actresses may influence young audiences for whom movie stars serve as role models  and there is enough evidence that smoking by movie stars can play an important role in even encouraging female adolescents to start smoking. 
Direct brand placement and tobacco product promotion
Values and lifestyles play a central role in the global marketing of tobacco to young adults, and tobacco companies are known to create associations between young adult values and tobacco brands.  It is now well known that owning tobacco promotional items and being able to recall cigarette advertisements can double the odds that an adolescent will become an established smoker. Movie images associate smoking with celebrities and depict it as an attractive behavior.  Evidence exists that adolescent smoking is partially attributable to aggressive tobacco marketing strategies aimed at youths through popular culture. Placing products or brand identifiers in movies is recognized as a standard marketing option to advertise and promote product use. 
The Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 banned all forms of direct and indirect advertisements of tobacco products. "Burning Brain Society" and many other organizations  have taken the initiative to study the impact of the Act on movies to depict the smoking scenes. In its analysis of 110 Hindi movies released between 2004 and 2005, Burning Brain Society studied the incidents of tobacco smoking in the Indian movies after 2003 and found that 89% of all the movies released contained smoking scenes. This is significantly higher than the previously reported 76% for movies release between 1990 and 2003.  The claim of the motion picture producers that tobacco is mostly shown to depict negative characters have been found to be baseless. Around 75.5% of the movies containing tobacco scenes depict either the male or the female lead consuming tobacco. Of all movies showing tobacco scenes, 80.6% of movies created a direct association of smoking with glamour. This accounts for 71.8% of all movies. 62.2% of movies showing tobacco promoted association of smoking with stress. There has also been an increased tendency to show female characters smoking and this was 28.6% of all tobacco smoking containing movies. This is much higher than the actual prevalence of smoking among women in India which has been reported at 2.5% among all sections of the society.  In many movies, the tobacco warning statements are either specifically or by actions trifled and mocked at. This figure was 30.6% for all tobacco-showing movies. In not even a single movie, tobacco has been shown to have caused any negative consequences. The gravest consequence was a verbal statement by a character that smoking is not good and often it was followed by another sequence belittling it or an actual smoking scene. Quite often, the leading character is shown with a cigarette in his mouth immediately before or after a heroic action. Tobacco companies are using motion pictures as a vehicle of clandestine promotion and advertisement of tobacco products in both generic and branded forms despite of the ban. 
Depictions of tobacco in Indian movies have increased significantly after the tobacco control legislation came into force. The product and brand visibility of tobacco products has also increased substantially. An erroneous relationship of tobacco with certain behavior and emotions is being created in the movies. Such associations are scientifically incorrect and were earlier also promoted by tobacco companies in their advertisements. It has been found that the youngsters get considerably influenced by tobacco visibility in moving images. There is also a high recall of tobacco brands visible in movies. The favorable impression created by movies showing tobacco is so high on the youngsters' mind that nearly half of all the youngsters desired holding a cigarette in their hand. For tobacco control efforts to succeed, this high impact on young minds and erroneous association with certain emotions and behavior patterns must be broken. A comprehensive ban on showing smoking or any form of tobacco consumption in electronic images or any other media will prove to be an effective step in this direction.
No doubt, tobacco use has declined in high-income countries; however, there have been sharp increases in tobacco use in lower- and middle-income countries in recent years. Though legally banned to the minors, tobacco products are easily available to children and adolescents. Tobacco companies are directly or indirectly promoting tobacco products and tobacco use continues to rise, aided and abetted by a sophisticated, wealthy, and powerful drug cartel based in New York and London.
| Recommendations|| |
Legal action against offenders
Action under Section 5 of "Cigarette and other Tobacco Products Act 2003" must be taken against the tobacco companies, film companies, producers, actors, and directors who have shown tobacco products, brands, or pack shots amounting to direct or indirect promotion and advertising in their movies after May 1, 2004.
Investigate the relationship and financial irregularities
Funding by tobacco companies like bearing a cost of a sequence of scenes; bearing the cost of film sets; and sponsorship in any form be investigated to ascertain the relationship of the movie companies and tobacco industry.
Recall the movies which show tobacco brand
The movie prints showing tobacco brands and product shots should be recalled and the film producers and companies should be asked to obliterate all such sequences and mention of tobacco with immediate effect.
Remove tobacco from children film completely
All the children animation/cartoon movies showing any instance of tobacco must be recalled immediately.
The CBFC role
The role of film certification board members who in disregard of the present censorship guidelines, cinematographic representation rules, and the legislative requirements, allowed quite apparent scenes of tobacco brand promotions through movies is intriguingly strange. Circumstances leading to such a scenario should be assessed and investigated so that such things do not happen in future.
Complete ban on depiction of tobacco
Tobacco has been perceived as a negative influence having no bearing on the decision of the public to watch a movie. It is perceived that the quality of the movie can in no way be affected by restricting tobacco depiction.  Public is concerned about the negative effects of tobacco depiction. 
Anti-tobacco advertisements on television
The national broadcaster and the other satellite channels should be asked to run regular anti-tobacco films and advertisement.
Ban surrogate advertisements
The presence of tobacco companies and tobacco brand logos on non-tobacco products should be considered tobacco brand promotion and subject to the same rules as direct tobacco promotion. Presently, many other products marketed by tobacco companies use the same trade name as that of the tobacco company and this creates an indirect psychological relationship with other tobacco products available bearing the same/similar insignia, logo, brand, or trade name. This needs to be stopped immediately. 
Foreign movies showing tobacco
The foreign movies showing tobacco must be regulated and those violating the guidelines must be prohibited entry into India with immediate effect.
Implementation of health warning
The need of the hour is that there should be immediate implementation of the already notified health warnings on tobacco products.
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Ram C Jiloha
Department of Psychiatry, Maulana Azad Medical College, G. B. Pant Hospital and Faculty of Medical Sciences, University of Delhi, New Delhi
Source of Support: None, Conflict of Interest: None